Person: GURBET, ALP
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GURBET
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Publication Is bispectral index monitoring reliable for determining sedation level in a tetanus patient?(Int Scientific Information, Inc, 2008-01-01) Girgin, Nermin Kelebek; KELEBEK GİRGİN, NERMİN; İşçimen, Remzi; İŞÇİMEN, REMZİ; Kutlay, Oya; Gurbet, Alp; GURBET, ALP; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anestezi ve Reanimasyon Anabilim Dalı.; 0000-0002-6503-8232; AAI-8104-2021; A-7994-2018; HKP-2533-2023; AAH-7250-2019Background: Tetanus is an infectious disease characterised by increased muscle rigidity, muscle spasms, and, in severe cases, cardiovascular instability secondary to autonomic dysfunction. Sedation is an important part of the treatment of tetanus. Clinical scoring systems, although simple and inexpensive, are often inadequate in evaluating the patient level of sedation in the intensive care unit (ICU). The bispectral index (BIS), a variable derived from the electroencephalography, could assess sedation in the ICU. In the present study, we aimed to present our experience on the application of BIS monitoring during treatment of a patient with tetanus.Case Report: A 69-year-old man was admitted to intensive care unit with a diagnosis of tetanus. The patient was intubated, and mechanical ventilation (MV) therapy with pressure support ventilation mode was administered. Dexmedetomidine, midazolam and morphine were administered for sedation and analgesia. Sedation was titrated to maintain a Ramsay Sedation Score (RSS) of 5 or greater. The RSS was assessed once a minute during the loading dose of dexmedetomidine and once an hour in the first day. On the following days, the RSS was recorded every 2 hours. When the RSS evaluation was applied, BIS values were also recorded simultaneously. On the 7th day, BIS monitoring could not be continued due to technical reasons. Sedation was monitored by RSS. A total number of 107 Ramsay score determinations and BIS values were obtained in the follow-up period. The patient underwent percutaneous tracheostomy on the 8th day. The patient was totally disconnected from MV on the 31st day and discharged from the hospital on the 33rd day.Conclusions: In this case, we thought that RSS is still a reliable method in monitoring the sedation level in tetanus. The BIS monitoring is inferior to and discordant with the standard monitoring of the RSS, largely to the painful muscle spasms and rigidity inherent in the pathophysiology of the disease. Moreover, if the sedative drug dosage is elevated according to BIS values, excessive sedation may occur in these patients.Publication Comparison of intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery(E-century Publishing Corp, 2022-01-01) Ogur, Lale; Akesen, Selcan; Goren, Suna; Kan, Irem Iris; Mogol, Elif Basagan; Gurbet, Alp; Akesen, Selcan; AKESEN, SELCAN; Goren, Suna; GÖREN, SUNA; Kan, Irem Iris; KAN, İREM İRİS; Mogol, Elif Basagan; MOĞOL, ELİF; Gurbet, Alp; GURBET, ALP; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anestezi ve Reanimason Anabilim Dalı.; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Kalp ve Damar Cerrahisihi Anabilim Dalı.; 0000-0002-6503-8232; A-7994-2018The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludag University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.Publication Comparison of two different doses of intrathecal levobupivacaine for transurethral endoscopic surgery(Aves, 2011-08-01) Dizman, Seçil; Türker, Gürkan; Gurbet, Alp; Moğol, Elif Başağan; Türkcan, Suat; Karakuzu, Ziyaatin; Dizman, Seçil; TÜRKER, YUNUS GÜRKAN; GURBET, ALP; MOĞOL, ELİF; Türkcan, Suat; Karakuzu, Ziyaatin; Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji Anabilim Dalı.; 0000-0002-3019-581X; 0000-0002-6503-8232; EUA-4272-2022; AAI-6642-2021; A-7994-2018; DHL-3236-2022; ECV-0145-2022; FFT-4429-2022Objective: To evaluate the effects of two different spinal isobaric levobupivacaine doses on spinal anesthesia characteristics and to find the minimum effective dose for surgery in patients undergoing transurethral resection (TUR) surgery.Materials and Methods: Fifty male patients undergoing TUR surgery were included in the study and were randomized into two equal groups: Group LB10 (n=25): 10 mg 0.5% isobaric levobupivacaine (2 ml) and Group LB15 (n=25): 15 mg 0.75% isobaric levobupivacaine (2 ml). Spinal anesthesia was administered via a 25G Quincke spinal needle through the L3-4 intervertebral space. Sensorial block levels were evaluated using the 'pin-prick test', and motor block levels were evaluated using the 'Bromage scale'. The sensorial and motor block characteristics of patients during intraoperative and postoperative periods and recovery time from spinal anesthesia were evaluated.Results: In three cases in the Group LB10, sensorial block did not reach the T10 level. Complete motor block (Bromage=3) did not occur in eight cases in the Group LB10 and in five cases in the Group LB15. The highest sensorial dermatomal level detected was higher in Group LB15. In Group LB15, sensorial block initial time and the time of complete motor block occurrence were significantly shorter than Group LB10. Hypotension was observed in one case in Group LB15. No significant difference between groups was detected in two segments of regression times: the time to S2 regression and complete sensorial block regression time. Complete motor block regression time was significantly longer in Group LB15 than in Group LB10 (p<0.01).Conclusion: Our findings showed that the minimum effective spinal isobaric levobupivacaine dose was 10 mg for TUR surgery.Publication Comparison of efficacy between the genicular nerve block and the popliteal artery and the capsule of the posterior knee (IPACK) block for total knee replacement surgery: A prospective randomized controlled study(Ortopedi Travmatoloji, 2021-03-01) Akesen, Selcan; Akesen, Burak; Atıcı, Teoman; Gurbet, Alp; Ermutlu, Cenk; Özyalçın, Ali; AKESEN, SELCAN; AKESEN, BURAK; ATICI, TEOMAN; GURBET, ALP; ERMUTLU, CENK; ÖZYALÇIN, ALİ; Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji ve Reanimasyon Anabilim Dalı; Uludağ Üniversitesi/Tıp Fakültesi/Ortopedi ve Travmatoloji Anabilim Dalı; 0000-0002-3396-3407; 0000-0002-6503-8232; AEQ-5464-2022; A-7994-2018; ELR-9087-2022; JHR-5447-2023Objective: The aim of this study was to compare the efficacy of popliteal artery and the capsule of the posterior knee (IPACK) block and genicular nerve block on postoperative pain scores, the need for rescue analgesics, range of motion (ROM), walking distance, and perioperative monitorization variables in patients undergoing total knee replacement (TKR) surgery.Methods: Sixty American Society of Anesthesiologists (ASA) physical status I-III patients were enrolled in this study and then were randomly assigned into three groups: the IPACK block group (17 female, 3 male; mean age=67.5 +/- 1.4 years), genicular nerve block (16 female, 4 male; mean age=68 +/- 1.76 years), and the control group (13 female, 7 male; mean age=63 +/- 1.67years). All the patients underwent TKR under spinal anesthesia. The visual analog scale (VAS) score, mobility, pre- and intra-operative monitorization of systolic and diastolic holding area, non-invasive blood pressure, heart rate, and SPO 2 were compared between the groups.Results: Patients in the IPACK and genicular block groups had a significantly lower visual analogous scale (VAS) at postoperative 4 hours (p<0.01), 8h (p<0.01), 12h (p<0.01), and 24h (p<0.05). VAS score was significantly lower in the genicular block group at the postoperative 4h (5.5 +/- 0.55) and 8h (5.0 +/- 0.53) in the mobile state compared to the IPACK (8.0 +/- 0.47 and 8.0 +/- 0.43, respectively) and the control group (9.5 +/- 0.20; 10 +/- 0.28, respectively) (p<0.01). The use of patient-controlled-analgesia (PCA) devices and button push count for analgesics demand were significantly lower in the genicular block group on the immediate postoperative period (p<0.01 at the postoperative 0 to 4 h). The total consumption of morphine equivalents on the postoperative day 0 was significantly lower in the genicular block group (p<0.01, and p<0.001 for IPACK and control groups, respectively). The degree of flexion was significantly higher in the genicular block group at the postoperative 12h compared to the IPACK and the control group (p<0.001). The length of hospital stay was significantly lower in the genicular block group compared to the IPACK and the control group (p<0.05 for both variables).Conclusion: IPACK and genicular blocks both are effective in improving patient comfort during and after TKR surgery and reducing the potential need for systemic analgesic and opioids. The genicular block seems to be a promising technique that can offer improved pain management in the immediate and early postoperative period without adverse effects on systemic and motor variables.Publication Comparison of blunt and sharp needles for transforaminal epidural steroid injections(Kare Publ, 2012-04-01) Özcan, Ulaş; Şahin, Şükran; Gurbet, Alp; GURBET, ALP; Çelebi, Sureyya; Türker, Gürkan; TÜRKER, YUNUS GÜRKAN; Özgür, Mustafa; YAYLI, MUSTAFA ÖZGÜR; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anestezi ve Reanimasyon Anabilim Dalı.; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Algoloji Anabilim Dalı.; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anestezi ve Reanimasyon Anabilim Dalı.; 0000-0002-6503-8232; 0000-0002-3019-581X; AAI-6642-2021; A-7994-2018Objectives: The aim of this study was to compare the sharp and blunt needles in order to determine the incidence of complications during transforaminal anterior epidural steroid injections.Methods: In this retrospective study, 185 cases that undergo transforaminal epidural steroid injection with sharp or blunt needles were evaluated between June 2004 and December 2008. Patients age, sex, diagnosis, needle type (sharp or blunt), volume of local anesthetic and steroid injected, complications (paresthesia, dural puncture, bleeding, paralysis, intravascular penetration, headache, local back pain, temporary motor loss in lower extremities) was recorded.Results: 3 cases in blunt needle group and 8 cases in sharp needle group showed paresthesia during the procedure. The difference was not found to be significant among the groups. Vascular penetration was observed in 2 cases in blunt and 13 cases in sharp needle group and the difference between groups was statistically significant (p<0.001). Dural puncture and headache incidence were not significant when the two groups are compared. The local back pain at the injection site had a higher incidence in the blunt needle group.Conclusion: When using the blunt needles, vascular penetration and paresthesia were less during transforaminal epidural steroid injections. Therefore blunt needles seem to be more advantageous.Publication Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy(Kare Publ, 2009-04-01) Arıcı, Semih; Gurbet, Alp; Türker, Gürkan; Yavaşcaoğlu, Belgin; Şahin, Şükran; Arıcı, Semih; GURBET, ALP; TÜRKER, YUNUS GÜRKAN; YAVAŞCAOĞLU, BELGİN; Şahin, Şükran; Uludağ Üniversitesi/Tıp Fakültesi/Anestezi ve Reanimasyon Anabilim Dalı.; 0000-0002-6503-8232; 0000-0002-3019-581X; 0000-0003-4820-2288; A-7994-2018; AAI-7914-2021; JZE-5924-2024; AAI-6642-2021; AAG-9356-2021Objectives: Paracetamol is primarily thought to be a cyclooxygenase inhibitor acting through the central nervous system. Indirect effects of paracetamol are through the serotoninergic system as a non-opioid analgesic. In this study, total abdominal hysterectomy patients were given intravenous (iv) paracetamol 1 g preoperatively or intraoperatively to assess its postoperative analgesic effects.Methods: 90 patients undergoing total abdominal hysterectomy were enrolled into the study. Patients were randomized into three groups: in Group I, iv paracetamol 1 g was given 30 minutes prior to induction. In Group II, iv paracetamol 1 g was given prior to skin closure. Group III served as the control group and received saline as placebo. Postoperatively, all patients received morphine via patient-controlled analgesia pump. Postoperatively, rest and activity pain scores, sedation scores, hemodynamic parameters, postoperative morphine consumption, side effects, patient satisfaction, and total hospital stay were recorded.Results: In the control group, at rest and movement pain scores and total morphine consumption via patient-controlled analgesia were higher than in Groups I and II. When Groups I and II were compared, total morphine consumption was much greater in Group II. Intravenous paracetamol intraoperatively and postoperatively did not result in any hemodynamic effects.Conclusion: In total abdominal hysterectomy, preemptive iv paracetamol 1 g provided good quality postoperative analgesia, with decreased consumption of morphine and minimal side effects.Publication Comparison of efficacy between the genicular nerve block and the popliteal artery and the capsule of the posterior knee (IPACK) block for total knee replacement surgery: A prospective randomized controlled study(Türkiye Ortopedi Travmatoloji, 2021-03-01) Akesen, Selcan; Akesen, Burak; Atıcı, Teoman; Gurbet, Alp; Ermutlu, Cenk; Özyalçın, Ali; AKESEN, SELCAN; AKESEN, BURAK; ATICI, TEOMAN; GURBET, ALP; ERMUTLU, CENK; ÖZYALÇIN, ALİ; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji ve Reanimasyon Anabilim Dalı; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Ortopedi ve Travmatoloji Anabilim Dalı; 0000-0002-3396-3407; 0000-0002-6503-8232; JHR-5447-2023; AEQ-5464-2022; ELR-9087-2022; AAH-9833-2021; A-5095-2018; A-7994-2018Objective: The aim of this study was to compare the efficacy of popliteal artery and the capsule of the posterior knee (IPACK) block and genicular nerve block on postoperative pain scores, the need for rescue analgesics, range of motion (ROM), walking distance, and perioperative monitorization variables in patients undergoing total knee replacement (TKR) surgery.Methods: Sixty American Society of Anesthesiologists (ASA) physical status I-III patients were enrolled in this study and then were randomly assigned into three groups: the IPACK block group (17 female, 3 male; mean age=67.5 +/- 1.4 years), genicular nerve block (16 female, 4 male; mean age=68 +/- 1.76 years), and the control group (13 female, 7 male; mean age=63 +/- 1.67years). All the patients underwent TKR under spinal anesthesia. The visual analog scale (VAS) score, mobility, pre- and intra-operative monitorization of systolic and diastolic holding area, non-invasive blood pressure, heart rate, and SPO 2 were compared between the groups.Results: Patients in the IPACK and genicular block groups had a significantly lower visual analogous scale (VAS) at postoperative 4 hours (p<0.01), 8h (p<0.01), 12h (p<0.01), and 24h (p<0.05). VAS score was significantly lower in the genicular block group at the postoperative 4h (5.5 +/- 0.55) and 8h (5.0 +/- 0.53) in the mobile state compared to the IPACK (8.0 +/- 0.47 and 8.0 +/- 0.43, respectively) and the control group (9.5 +/- 0.20; 10 +/- 0.28, respectively) (p<0.01). The use of patient-controlled-analgesia (PCA) devices and button push count for analgesics demand were significantly lower in the genicular block group on the immediate postoperative period (p<0.01 at the postoperative 0 to 4 h). The total consumption of morphine equivalents on the postoperative day 0 was significantly lower in the genicular block group (p<0.01, and p<0.001 for IPACK and control groups, respectively). The degree of flexion was significantly higher in the genicular block group at the postoperative 12h compared to the IPACK and the control group (p<0.001). The length of hospital stay was significantly lower in the genicular block group compared to the IPACK and the control group (p<0.05 for both variables).Conclusion: IPACK and genicular blocks both are effective in improving patient comfort during and after TKR surgery and reducing the potential need for systemic analgesic and opioids. The genicular block seems to be a promising technique that can offer improved pain management in the immediate and early postoperative period without adverse effects on systemic and motor variables.Publication Comparison of intraoperative and post-operative effects of serratus anterior plane block performed with ultrasound and infiltration block in patients undergoing video-assisted thoracoscopic surgery(Kare Publ, 2022-01-01) Dikici, Mustafa; Akesen, Selcan; YAVAŞCAOĞLU, BELGİN; AKESEN, SELCAN; BAYRAM, AHMET SAMİ; Bayram, Ahmet Sami; Kaya, Fatma Nur; KAYA, FATMA NUR; Gurbet, Alp; GURBET, ALP; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji ve Reanimasyon Anabilim Dalı.; 0000-0003-0684-0900; 0000-0002-6503-8232; A-7994-2018; ABB-7580-2020Objectives: We aimed to compare the intraoperative and post-operative analgesic activities of the preventive applied serratus anterior plane (SAP) block and infiltration block in patients undergoing video-assisted thoracoscopic surgery (VATS).Methods: The study was carried out in 60 patients aged between 18 and 80 who were eligible for elective VATS, with the American Society of Anesthesiologists classification I-II, following ethical committee approval and written informed consent form. Patients were divided into two groups as SAP (group serratus anterior plane block [SAPB]) and group infiltration block after routine monitoring and general anesthesia induction by recording demographic data after randomization. Hemodynamic data of all patients were recorded before, after induction and within intraoperative 30 min period. Patient controlled analgesia (PCA) prepared with morphine was applied to all patients postoperatively. Intraoperative hemodynamic data and opioid consumption of patients, resting time, and coughing visual analog scale, time to first PCA dose, post-operative opioid consumption, rescue analgesic requirement, mobilization times, opioid side effects, and patient and surgical team's satisfaction were evaluated.Results: Intraoperative hemodynamic data and opioid consumption were similar between the two groups. Post-operative pain scores (0 and 30 min, 1, 2, 4, 8, and 12 h) were lower in the SAPB group (p<0.005) and time to use the first PCA (p=0.002) was longer in the SAPB group. Post-operative PCA and rescue analgesic requirement were lower in the SAPB group (p=0.002, p=0.00). It was found that the first mobilization time was shorter in the SAPB group (p=0.003), and opioid-related side effects were similar in both groups (p=0.067). Patient and surgical team satisfaction was high in the SAPB group (p=0.004, p=0.000).Conclusion: As a result, more effective post-operative analgesia was provided with preventively SAPB, compared to infiltration block in patients undergoing VATS.Publication The effect of combined pulsed radiofrequency treatment to dorsal root ganglion with transforaminal epidural steroid injection on pain(Kare Publ, 2021-01-10) Çalışkan, Duygu Karaköse; Akesen, Selcan; Türker, Yunus Gürkan; Gurbet, Alp; AKESEN, SELCAN; TÜRKER, YUNUS GÜRKAN; GURBET, ALP; Bursa Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji ve Reanimasyon Anabilim Dalı.; 0000-0002-3019-581X; 0000-0002-6503-8232; 0000-0002-9518-541X; AAI-6642-2021; A-7994-2018; ELR-9087-2022Objectives: We aimed to compare the treatment response with simultaneous application of transforaminal epidural steroid injection (TESI) and pulsed radiofrequency (PRF) to the lumbar dorsal root ganglion (DRG) with TESI in patients with chronic lumbar radicular pain.Methods: A total of 129 patients were enrolled. TESI was performed to 67 patients and TESI+DRG-PRF was performed to 62 patients. Demographic data, surgical records, and medications, side, and level of the procedure were recorded. Patients were evaluated on the pre-operative and post-operative 10th day, 1st and 3rd month follow-up visits, and visual analog scale (VAS, 0-10) scores, and patients' satisfaction assessment on the 3rd month follow-up were collected. A successful therapeutic response was defined as a 50% or more reduction in VAS scores.Results: In both groups, post-operative VAS scores were significantly lower than the pre-operative levels (p<0.001). VAS scores in the TESI+DRG-PRF group were significantly lower than the TESI group at all follow-up periods (p<0.001). Reduction ratios in VAS scores were significantly higher in the TESI+DRG-PRF group in all follow-up visits (p<-0.001). Satisfaction levels were significantly higher in the TESI+DRG-PRF group (p<0.01).Conclusion: According to our study, TESI provides short-moderate pain relief in patients with chronic lumbar radicular pain. A simultaneous application of PRF in the same session with TESI should be considered as an option to improve the treatment response.Publication Conscious sedation for endoscopic retrograde cholangiopancreatography: Dexmedetomidine versus midazolam(Aves, 2011-04-01) Kılıç, Neslihan; Şahin, Şükran; Aksu, Hale; Yavaşcaoğlu, Belgin; Gurbet, Alp; Türker, Gürkan; Kadıoğlu, Aslı Güler; Kılıç, Neslihan; Şahin, Şükran; Aksu, Hale; YAVAŞCAOĞLU, BELGİN; GURBET, ALP; TÜRKER, YUNUS GÜRKAN; Kadıoğlu, Aslı Güler; Uludağ Üniversitesi/Tıp Fakültesi/Anesteziyoloji ve Reanimasyon Anabilim Dalı.; 0000-0002-4887-1337; 0000-0003-4820-2288; 0000-0002-6503-8232; 0000-0002-3019-581X; A-7994-2018; AAG-9356-2021; AAI-7914-2021; AAI-6642-2021; FDK-6768-2022; DPH-3881-2022; AAO-7943-2020; ILV-9196-2023Objective: Midazolam and dexmedetomidine, which are used for sedation during endoscopic retrograde cholangiopancreatography, were compared to evaluate the differences in efficacy, hemodynamics, and side effects.Materials and Methods: Fifty patients aged between 18 and 80 were randomly assigned to two groups according to American Society of Anesthesiologists (ASA) classification: Group M received midazolam with an initial bolus infusion of 0.04 mg/kg intravenously (i.v.), followed by additional doses of 0.5 mg i.v. midazolam, titrated to achieve a Ramsay sedation scale score of 3-4. Group D received dexmedetomidine with an initial bolus infusion of 1 mcg/kg/hr i.v. over 10 minutes, followed by a continuous infusion of 0.2-0.7 mcg/kg/hr, titrated to achieve an RSS of 3-4. A Mini Mental Status Examination (MMSE) was performed prior to sedation and in the recovery room once the Modified Aldrete Score (MAS) reached 9-10. Patient heart rates, arterial pressure and pain were evaluated.Results: Patients in Group D had lower heart rates at 20, 25, 30, 35 and 40 minutes following the initiation of sedation (p<0.05). There was no statistical difference in arterial pressure, RSS, MMSE or respiratory rate between the two groups. Coughing, nausea and vomiting occurred in 3 patients in Group M (12%), whereas no patient in Group D experienced these symptoms. The procedure elicited a gag response in 7 patients in Group M (28%) and in 4 patients in Group D (16%), with no significant difference between groups (p>0.05). When patient and surgeon satisfaction was compared between the two groups, Group D showed higher surgeon satisfaction scores (p<0.05).Conclusion: The use of dexmedetomidine for conscious sedation during short, invasive procedures, such as endoscopic retrograde cholangiopancreatography, could be a superior alternative to the use of midazolam.